The importance of quality data to track global progress in addressing stillbirths and neonatal mortality
Authors: Sarah Saleem, Elizabeth M McClure
Journal: The Lancet Global Health (2023)

About 2·4 million neonatal deaths1GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (493) Google Scholar and 2·0 million stillbirths2Hug L You D Blencowe H et al.Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment.Lancet. 2021; 398: 772-785Summary Full Text Full Text PDF PubMed Scopus (82) Google Scholar occur each year globally, with 98% of these deaths occurring in low-income and middle-income countries (LMICs). Accurate counting of stillbirth and neonatal deaths is crucial to understanding the true burden of mortality and necessary to understanding countries' progress towards meeting national and international health goals, such as the UN Sustainable Development Goals (SDGs). Only a small fraction of these deaths are registered and the challenges of registering these deaths, including limited resources, cultural considerations, and competing priorities are well documented. Instead, most LMICs rely on periodic household surveys, most commonly the demographic and health surveys (DHS), for health indicators. However, DHS have well known limitations, especially in recording stillbirths and early neonatal deaths.3Christou A Dibley MJ Raynes-Greenow C Beyond counting stillbirths to understanding their determinants in low- and middle-income countries: a systematic assessment of stillbirth data availability in household surveys.Trop Med Int Health. 2017; 22: 294-311Crossref PubMed Scopus (21) Google Scholar In this issue of Lancet Global Health, Mohamed M Ali and colleagues4Ali MM Bellizzi S Boerma T Measuring stillbirth and perinatal mortality rates through household surveys: a population-based analysis using an integrated approach to data quality assessment and adjustment with 157 surveys from 53 countries.Lancet Glob Health. 2023; (published online May 8.)https://doi.org/10.1016/S2214-109X(23)00125-0Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar address the quality of data to assess neonatal mortality in DHS and propose strategies that could be used to improve the usefulness of these surveys to track stillbirth and neonatal mortality. To date, neonatal mortality is obtained through questions regarding the mother's livebirth history, whereas stillbirths are documented through supplemental questions or a pregnancy history, which generally under-reports stillbirths. Because the DHS is the main source of vital registration for LMICs, the authors sought to identify methods to overcome these limitations to improve the usefulness of the available data. They focused on three main limitations: misreporting of age of neonatal death; omission or transferring of stillbirths; and early neonatal deaths. Through analyses of 157 DHS from 53 countries, the authors found data heaping of neonatal deaths at day 7 as well as under-reporting of stillbirths and very early neonatal deaths in most surveys. Analytical strategies to address these limitations include evaluating whether heaping has occurred and assessing the ratio of neonatal deaths to stillbirths. By doing simple quality checks and adjusting the data, if needed, the usefulness of DHS data is greatly improved. Registration of all births—and deaths—is a crucial goal but will probably take years to achieve in many LMICs. In the interim, although research studies that prospectively enrol and document all mortality are the gold standard,5McClure EM Garces AL Hibberd PL et al.The Global Network Maternal Newborn Health Registry: a multi-country, community-based registry of pregnancy outcomes.Reprod Health. 2020; 17: 184Crossref PubMed Scopus (10) Google Scholar surveys such as DHS are one of the main sources of data to assess the burden of mortality globally. Understanding both the strengths and limitations of DHS is important to using these data effectively. With the upcoming targets of the SDGs in 2030, leveraging available data sources and improving data quality using methods such as those proposed by Ali and colleagues3Christou A Dibley MJ Raynes-Greenow C Beyond counting stillbirths to understanding their determinants in low- and middle-income countries: a systematic assessment of stillbirth data availability in household surveys.Trop Med Int Health. 2017; 22: 294-311Crossref PubMed Scopus (21) Google Scholar will help to better measure our progress, and also to instil confidence in public policy makers and the broader public health community. Although the method proposed by Ali and colleagues has its own limitations and subjectivity in arriving at the cutoff values for the proposed indicators, and its universal acceptability and applicability to future DHS in LMICs require further validation, it is still an important step towards adjusting for inherent misreporting of age of neonatal death, omission of stillbirths and early neonatal deaths, and transferring stillbirths and early neonatal deaths. Substantial resources have been invested in the DHS, which are typically carried out every 5 years on a large scale with multiple individuals involved in conducting these surveys. Controlling quality of data remains a big challenge, especially regarding information on mortality and on culturally sensitive topics such as stillbirth and early neonatal deaths (particularly within a few hours of birth), which carries a stigma. Training the interviewers for proper probing around the timing of events and understanding the questions and potential inaccuracy of the responses on stillbirth and early neonatal mortality will remain concerns in coming years.6Asim M Karim S Khwaja H Hameed W Saleem S The unspoken grief of multiple stillbirths in rural Pakistan: an interpretative phenomenological study.BMC Womens Health. 2022; 22: 45Crossref PubMed Scopus (4) Google Scholar Hence, attempts to adjust for missing information, misreporting and transferring stillbirths, and neonatal mortality in analyses of DHS results could be a good initial step to improve accuracy of results. Furthermore, it will be interesting to understand the implications of similar adjustments for data from high-income countries, as well as for cutoffs for gestations of at least 20 weeks in LMICs. Ultimately, complete vital registration of all stillbirths and neonatal deaths should be the standard for all countries. However, given the realities of competing interests and limited resources considered together with the substantial efforts already invested in DHS, the analytical efforts to improve the quality of the data are an important step forward. We declare no competing interests. Measuring stillbirth and perinatal mortality rates through household surveys: a population-based analysis using an integrated approach to data quality assessment and adjustment with 157 surveys from 53 countriesA simultaneous focus on stillbirths and early neonatal mortality facilitates a comprehensive assessment of inaccurate reporting in household surveys and allows for better use of surveys in planning and monitoring of efforts to reduce stillbirths and early neonatal mortality. Full-Text PDF Open Access